Utility of the Physical Examination in Detecting Pulmonary Hypertension. A Mixed Methods Study

Abstract

IntroductionPatients with pulmonary hypertension (PH) often present with a variety of physical findings reflecting a volume or pressure overloaded right ventricle (RV). However, there is no consensus regarding the diagnostic utility of the physical examination in PH.MethodsWe conducted a systematic review of publications that evaluated the clinical examination and diagnosis of PH using MEDLINE (1946–2013) and EMBASE (1947–2013). We also prospectively evaluated the diagnostic utility of the physical examination findings. Patients who underwent right cardiac catheterization for any reason were recruited. After informed consent, participants were examined by 6 physicians (3 “specialists” and 3 “generalists”) who were unaware of the results of the patient's hemodynamics. Each examiner independently assessed patients for the presence of a RV lift, loud P2, jugular venous distension (JVD), tricuspid insufficiency murmur and right-sided 4th heart sound at rest and during a slow inspiration. A global rating (scale of 1–5) of the likelihood that the patient had pulmonary hypertension was provided by each examiner.Results31 articles that assessed the physical examination in PH were included in the final analysis. There was heterogeneity amongst the studies and many did not include control data. The sign most associated with PH in the literature was a loud pulmonic component of the second heart sound (P2). In our prospective study physical examination was performed on 52 subjects (25 met criteria for PH; mPAP ≥25 mmHg). The physical sign with the highest likelihood ratio (LR) was a loud P2 on inspiration with a LR +ve 1.9, 95% CrI [1.2, 3.1] when data from all examiners was analyzed together. Results from the specialist examiners had higher diagnostic utility; a loud P2 on inspiration was associated with a positive LR of 3.2, 95% CrI [1.5, 6.2] and a right sided S4 on inspiration had a LR +ve 4.7, 95% CI [1.0, 15.6]. No aspect of the physical exam, could consistently rule out PH (negative LRs 0.7–1.3).ConclusionsThe presence of a loud P2 or audible right-sided 4th heart sound are associated with PH. However the physical examination is unreliable for determining the presence of PH.

Pulmonary hypertension: diagnostic approach and optimal management

“…A systematic review showed that the most specific and thus greatest predictive finding of PH was a loud P 2 (positive likelihood ratio 56.4, 95% CI 7.9-401.7). 17 In a prospective cohort study, however, the same authors found that an accentuated P 2 was only weakly predictive (posi tive likelihood ratio 1.9, 95% CI 1.2-3.1). 17 The diagnostic strength of other signs is poor, as most features have a negative likelihood ratio approximating 1.…”

“…17 In a prospective cohort study, however, the same authors found that an accentuated P 2 was only weakly predictive (posi tive likelihood ratio 1.9, 95% CI 1.2-3.1). 17 The diagnostic strength of other signs is poor, as most features have a negative likelihood ratio approximating 1. Characteristic features on common noninvasive investigations can also indicate the presence of PH, any of which should prompt further diagnostic work-up (Box 3).…”

“…11,12 A retrospective multivariable analy sis of three large studies of acute pulmonary embolism showed that the strongest predictive factors for future CTEPH were unprovoked pulmonary embolism (RR 18, 95% CI 1.8 to > 100) and right ventricular dysfunction on computed tomographic pulmonary angiography or echocardiography (RR 5.9, 95% CI 1. [8][9][10][11][12][13][14][15][16][17][18][19]. 13 Importantly, one-third to one-half of patients with CTEPH have no prior history of venous thromboembolism, such that CTEPH cannot be excluded on the basis of clinical history alone.…”

La clínica en la hipertensión pulmonar del adulto

“…Un profesional con un oído entrenado probablemente tendría menos dificultad para reconocer el reforzamiento del componente pulmonar del segundo ruido (S 2 ) en comparación con alguien con menos experiencia. 6 De manera similar, un médico que no está acostumbrado a evaluar los sonidos originados del lado derecho del corazón puede que no aprecie con facilidad los sonidos que son más intensos, o sólo perceptibles durante la inspiración, como un cuarto ruido (S 4 ) cardíaco derecho. 6 La auscultación cardíaca es un proceso altamente cognitivo influenciado por factores del paciente, así como también por el sesgo heurístico del profesional, que contribuye a un acuerdo pobre entre observadores.…”

“…6 De manera similar, un médico que no está acostumbrado a evaluar los sonidos originados del lado derecho del corazón puede que no aprecie con facilidad los sonidos que son más intensos, o sólo perceptibles durante la inspiración, como un cuarto ruido (S 4 ) cardíaco derecho. 6 La auscultación cardíaca es un proceso altamente cognitivo influenciado por factores del paciente, así como también por el sesgo heurístico del profesional, que contribuye a un acuerdo pobre entre observadores. 7 Por otro lado, la exclusión es un proceso de diagnóstico muy útil sobre todo cuando se conocen a fondo los padecimientos por excluir.…”